One of the new trends in health insurance is the emergence of high deductible health plans. As employers try to control year-over-year increases in providing their employees with a health insurance benefit, many small and medium-size companies are turning to health plans with higher deductible amounts. Deductibles of $1,000 for individual coverage and $2,000 for family coverage are typical of high deductible plans.
To fill the deductible gap, some employers will fund a portion of the deductible amount through an Internal Revenue Service (IRS) approved Health Reimbursement Arrangement (HRA) or Health Savings Account (HSA). With HSAs, employees can also contribute funds up to the annual amount limits as defined by the IRS (if the plan meets IRS requirements for a high deductible plan).
A growing challenge for healthcare providers (doctors, hospitals, pharmacies) is to ensure that they receive payment from their patients who may not be eligible for health insurance plan reimbursement until the plan deductible is met. Currently, however, a healthcare provider (for example, a doctor) does not know at the time of service what portion of the doctor's bill for services will be the patient's responsibility and what portion will be paid by a payer, typically a health insurance company. In fact, it is typically only after the patient's visit that the amount for which the patient is responsible is determined.
The amount for which the patient is responsible, is determined by the doctor and the payer in what is called an “adjudication”. The adjudication process can be a function of one or more factors, examples of which include the patient's current health plan coverage, services performed by the provider, contracted rates between the doctor and the payer, and the patient's current accumulated deductible.
The result is paperwork, administrative expense, and a long collection cycle. If the patient chooses not to pay, the expense incurred by the provider to collect payment from the patient may be so great that the provider simply elects to write off the uncollected amount.
Accordingly, there is a need in the art for methods and systems of processing healthcare claims that serve to assure healthcare providers of receiving payment for services rendered. Embodiments of the invention address this and other problems.